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111 41 ] 

OREGON DEPIARTMENT OF ENVIRONMENTAL QUALITY 

UNDERGROUND STORAGE TANK PROGRAM 

30-DAY NOTICE OF INTENT TO DECOMMISSION USTS 

OR COMPLETE A CHANGE-IN-SERVICE 

1. FACILITY (Location of Tanks) {Please Print) 

Name: 

Address: 

2. FERMITIEE (PleasePrint) 

Name: 

Address: 

••<:::!:v?;;;v:.:;;-^ V. \ %::':-'•-".'- r •• •;-^: •.-. •^•:'.-:•: 

Phone: Phone: 

DEQ General Permit Operating Certificate Number: 

Work To Be Performed By: • 

(Permittee, Tank Owner, Property Owner or License 

Phone: Mobile Phone: 

License # 

d Service Provider) (Service Provider) 

-' 

^9D . 

THIS FORM MUST BE SUBMITTED BY UST PERMITTEE 30 DAYS BEFORE START OF WORK 

YOU MUST CONTACT YOUR LOCAL DEQ REGIONAL OFFICE 3-DAYS BEFORE STARTING ANY 

DECOMMISSIONING WORK. (Phone numbers are listed on Page 2) 

No IJVill tank removal or potential cleanup affect adjacent property or Right-of-Way property? Yes 

ate decommissioning is scheduled to begin: "-•. . -: • • ••• 

TANK 

ID# 

DEQ-UST 

PERMIT # 

TANK SIZE 

IN 

GALLONS 

PRODUCT: GASOLINE, 

DIESEL, USED OIL, 

OTHER? 

PRESENT NEW 

CLOSURE OR CHANGE-IN- SERVICE? 

TANK 

REMOVAL 

n 

CLOSURE 

IN 

PLACED 

CHANGE 

IN 

SERVICE* 

TANK TO BE 

REPLACED? 

YES* NO 

* If decommissioned tank(s) are to be replaced by new imderground storage tanks you must submit a General Permit 

Registration Form to Install and Operate USTs for the new tanks 30 days before installing them. 

• Submit a soil sampling plan to the DEQ regional office and receive plan approval prior to starting work if (1) tank is to 

be decommissioned in-place, (2) tank contents are changed to an unregulated substance or (3) tank contains a regulated 

substance other than petroleum. 

« 

Permittee: W:WW:::MM 

Permittee: 

Ss;: ::;;:;:;:;:; SisBSSS:;::; Wm m ffiSSS 

(Please Print) 

(Signature) 

Date: 

1 

( 

August 2007 Page lo f 2 DEQ-05-LQ-020A 
THIS NOTICE AND THE 3-DAY TELEPHONE NOTICE ARE REQUIRED prior to starting decommissioning work on a 

regulated underground storage tank (UST). Decommissioning work includes but is not limited to excavation and removal ofthe tank 

and its appurtenances, removafof underground piping (product, vent and vapor recovery piping), soil sampling, and groundwater 

sampling. (Decommissioning USTs or completing a change-in-service must be done in accordance with the conditions and 

requirements of OAR 340-150-0166, the general permit to decommission USTs). 

THIS NOTICE IS NOT REQUIRED for decommissioning unregulated tanks. To determine whether an underground tank is 

regulated please refer to OAR 340-150-0008 for UST's that are excluded or deferted from regulation, and OAR 340-150-0010 (82) 

for the defmition of a UST, or contact DEQ. (Examples are heating oil, and most residential or farm motor fuel tanks under 1100 

gallons.) 

ALL PAST DUE UST GENERAL PERMIT ANNUAL COMPLIANCE FEES MUST BE PAID before this decommissioning 

notice will be accepted by DEQ. 

MAKE SURE THIS FORM IS COMPLETE WITH ALL ATTACHMENTS as a notice that is incomplete will not be accepted. 

RETURN COMPLETED AND SIGNED FORM TO THE DEQ REGIONAL 

OFFICE FOR YOUR AREA (Addresses are listed below). 

3-DAY NOTICE: Contact your local DEQ Regional Office 3-days before starting work. 

(Phone numbers are listed below). 

NORTHWEST REGION 

Clackamas? Clatsop, 

Columbia, Multnomah, 

Tillamook & Washington 

Counties 

WESTERN REGION: Benton, 

Coos, Curry, Douglas, Jackson, 

Josephine, Polk, Lane, Lincoln, 

Linn, Marion & Yamhill Counties 

EASTERN 

REGION: 

Baker, Crook, 

Deschutes, 

Gilliam, Grant, 

Harney, Hood 

River, Jefferson, 

Klamath, Lake, 

Malheur, 

Morrow, 

Sherman, 

Umatilla, Union, 

Wasco, Wheeler 

& Wallowa 

Counties 

EASTERN REGION / THE DALLES 

400 E. Scenic Drive, Building 2 - 307 

The Dalles, OR 97058 

Phone: 541-298-7255 

Fax: 541-298-7330 

NORTHWEST REGION 

2020 SW 4th Avenue, Suite 400 

Portland, OR 97201-5884 

Phone: 503-229-5263 

Fax: 503-229-6945 

WESTERN REGION / COOS BAY 

381 N SECOND STREET 

COOS BAY 97420 

Phone: 541-269-2721 

Fax:541-269-7984 

WESTERN REGION / EUGENE 

1102 Lincoln Street, Suite 210 

Eugene, OR 97401 

Phone: 541-686-7838 

Fax: 541-686-7551 

WESTERN REGION / SALEM 

750 Front Street NE, Suite 120 

Salem, OR 97301-1039 

Phone: 503-378-8240 

Fax: 503-373-7944 

For information or assistance with this form call (503) 229-6652 or the UST HELPLINE: 

1-800-742-7878 (Toll Free in Oregon). 

Program information, registration forms, administrative rules- and 

other publications can also be found on our Homepage at: 

http://www.deq.state.or.us/lq/tanks/ust/index.htin 

August 2007 Page 2 of 2 DEQ-05-LQ-020A 

•^c ^ 

DEQ 

state of Ons^xi 

DepsftiKient of 

Envltanmeiital 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

UNDERGROUND STORAGE TANK PROGRAM 

UNDERGROUND STORAGE TANK DECOMMISSIONING 

CHECKLIST AND SITE ASSESSMENT REPORT 

A. FACILITY INFORMATION: 

This report MUST be submitted by the underground storage tarik permittee or tank owner, or the licensed DEQ 

Service Provider on their behalf, within 30 days following completion of the tank decommissioning or 

change-in-service regardless of ongoing cleanup work. . 

DEO FACILITY NUMBER: 

FACILITY NAME: 

FACILITY ADDRESS: 

PERMITTEE PHONE: 

1 

DATE: 

|B. WORK PERFORMED BY: 

The checklist and site assessment report should be completed and signed by the DEQ licensed supervisor and signed by an 

executive officer ofthe DEQ licensed Service Provider on page 6. The tank owner or permittee must review and sign the 

report on page 6. NOTE: AN OWNER OR PERMITTEE MAY PERFORM UST SERVICES ONLY IF THEY 

HAVE TAKEN AND PASSED THE APPROPRIATE UST SUPERVISOR EXAMINATION OFFEREDBY A 

NATIONAL TESTING SERVICE (SEE OAR 340-150-0156 for requirements). 

DEQ Service Provider's License #: Construction Contractors Board License #: 

1 

Name: 

Telephone: 

DEQ Decommissioning Supervisor's License #: 

Name: 

Telephone: 

DEQ Soil Matrix Service Provider's License #: 

Name: ; 

Telephone: 

DEQ Soil Matrix Supervisor's License #: 

Name: : 

Telephone: \ 

(If applicable) 

(If applicable) 

August 2007 Page 1 of 7 DEQ-08-LQ-073 
C. DATES: 

Note: 

servic 

contai 

Decommissioning/Chahge-in-Service Notice - Date Submitted: 

Work Start Telephone Notice - Number issued by DEQ: 

DEO Person Notified: 

Date Work Started: • Date Work Completed: 

(30 days before work starts). J 

i 

(3 working days before work starts). 

V. 

Provide the following information if any soil or water contamination is found during the decommissioning or change-ine. Contamination must be reported by the UST permittee within 24 hours. The licensed service provider must report 

tnination within 72 hours after discovery unless previously reported. 

Date Contamination Reported: By: , 

DEO Person Notified: 

D. OTHER DEQ PERMITS MAY BE NEEDED WHERE SOIL OR WATER CLEANUP IS REQUIRED. 

DEO Water Discharge Permit #: 

Water Disposed to (Location): 

DEO Solid Waste Disposal Permit #: 

Soil Disposal or Treatment Location: : 

Date: 

Date : i 

E. TANK INFORMATION: 

TANK 

ID# 

DEQ-UST 

PERMIT # 

TANK SIZE 

IN 

GALLONS 

: •• • ! • ' . • ^• -

\-M^:<::^ 

'i::Wf!M::^y-':;S:::<: 

PRODUCT: GASOLINE, 

DIESEL, USED OIL, 

OTHER? 

PRESENT NEW 

CLOSURE OR CHANGE-EN- SERVICE? 

TANK 

REMOVAL 

CLOSURE 

IN 

PLACE* 

CHANGE 

IN 

SERVICE* 

TANK TO BE 

REPLACED? 

YES NO 

NOTE 1: Where decommissioned tank(s) are replaced by new underground storage tanks the UST permittee must submit a General 

Permit Registration Form to Install and Operate USTs containing information on the new tanks 30 days before installing them. 

NOTE 2: Submit a soil sampling plan to the DEQ regional office and receive plan approval prior to starting work if 1) tank is to be 

decommissioned in-place, 2) tank contents are changed to a non-regulated substance, 3) tank contains a regulated substance other thanf 

petroleum, or 4) tank changed to non-regulated use. 

August 2007 Page 2 of 7 DEQ-08-LQ-073 
F. DISPOSAL INFORMATION: 

TANK 

ID# 

TANK AND PIPING DISPOSAL METHOD 

SCRAP LANDFILL OTHER IDENTIFY LOCATION 

& PROPERTY OWNER 

;'•' • ':'^ • V ' ' -:'^ \ : . 

DISPOSAL LOCATION OF TANK CONTENTS 

LIQUIDS 

-

SLUDGES 

' ' -^ 

. • • • • • •..'. . "- • 

NOTE 1: The tank contents, the tank and the piping may be subject to the requirements of Hazardous Waste regulations. If you have 

questions, contact the DEQ regional office for your area. 

NOTE 2: Attach copies ofthe disposal receipts for the tanks and piping. If the tanks are shipped off-site for reuse provide the name, 

address and phone number of the person or business receiving the tanks for reuse. 

NOTE 3: Attach copies ofthe disposal receipts for the disposal or treatment of liquid or sludge removed fi'om the tanks 

G. CONTAMINATION INFORMATION: 

TANK 

ID# 

GROUND 

WATER 

IN PIT? 

PRODUCT 

ODOR IN 

SOIL? 

PRODUCT 

STAINS 

IN SOIL ? 

NUMBER 

OF 

SAMPLES 

LABORATORY 

(NAME, CITY, STATE, PHONE) 

NOTE 1: Attach a copy ofthe laboratory report showing the results of all tests on all soil and water samples. The laboratory report 

must identify sample collection methods, sample location, sample depth, sample type (soil or water), type of sample container, sample 

temperature during fransportation, types of tests, and copies of analytical laboratory reports, including QA/QC information. Include 

laboratory name, address and copies of chain-of-custody forms. 

NOTE 2: If contamination is detected and a Level 2 or Level 3 soil mattix cleanup standard is applied to the site, attach a copy ofthe 

soil mattix analysis including methods of determining soil type, depth to groundwater, and sensitivity of uppermost aquifer. 

r 

August 2007 Page 3 of 7 DEQ-08-LQ-073 
H. SITE SKETCH: (Show location of adjacent roads, property lines, structures, dispensers, & all USTs. Show North, 

general direction of ground slope and soil sample locations. Sketch does not need to be drawn to scale. You may attach a 

separate drawing.) u 

August 2007 Page 4 of 7 DEQ-08-LQ-073 
L SAFETY EQUIPMENT ON JOB SITE: 

LFire Extinguisher: 

Combustible Gas Detector: 

Oxygen Analyzer: 

Type/Size: 

Model: 

Model:-

Recharge Date: 

Calibration Date: 

Calibration Date: 

J. DECOMMISSIONING: 

All Tanks: N/A = Not Applicable (Check (V) Appropriate Box) 

1. All elecfrical equipment grounded and explosion proof? 

2. Safety equipment on job site? 

3. Overhead electtical lines located? 

4. Subsurface electrical lines off or disconnected? 

5. Natural gas lines off or disconnected? 

6. No open fires or smoking material in area? 

7. Vehicle and pedesttian ttaffic conttolled? 

8. Excavation material area cleared? 

9. Rainwater runoff directed to tteattnent area? 

10. Drained and collected product from lines? 

11. Removed product and residual from tank? 

12. Cleaned tank? 

13. Excavated to top of tank? 

14. Removed tank fixtures? (pumps, leak detection equipment) 

15. Removed product, fill and vent lines? 

YES NO UNKNOWN N/A 

K. TANK ABANDONMENT IN-PLACE: 

All Tanks: N/A = Not Applicable (Check (V) Appropriate Box) 

16. Sampling plan approved by DEQ? 

Date: DEQ Staff: 

17. Contamination concems fully resolved? 

18. Fill Material? Type: 

YES NO UNKNOWN N/A 1 

1 

August 2007 Page 5 of 7 DEQ-08-LQ-073 
L. TANK REMOVAL: 

All Tanks: N/A = Not Applicable (Check (V) Appropriate Box) 

19. Tank placement area cleared, chocks placed? 

20. Purged or ventilated tank to prevent explosion? 

Method used: :•::§•:: S •* 

Meter reading: '':::.?::'^ 

21. Were chains or steel cables wrapped around tank for removal? 

22. Tank removed, set on ground, blocked to prevent movement? 

23. Tank set on truck and secured with sttaps(s)? 

24. Tank labeled before leaving site? . 

YES NO 

/:•-.> : 

UNKNOWN N/A 1 

M. SITE ASSESSMENT: 

All Tanks: N/A = Not Applicable (Check (V) Appropriate Box) 

25. Site assessed for contamination? See OAR 340-122-0340 

26. Soil samples taken and analyzed? 

27. Was contamination found? Date/Time: <: 

28. Was hazardous waste determination made for tank contents 

(Liquids/sludges)? 

YES NO UNKNOWN N/A 1 

'. ,•::•• • 

N. REQUIRED SIGNATURES: 

I have personally reviewed this decommissioning checklist and site assessment report and the attachments and fmd 

them to be true and complete. 

Perriiittee or Tank Owner: 

(Please Print) 

Permittee or Tank Owner: Date: 

(Signature) 

I have personally reviewed this decommissioning checklist and site assessment report and the attachments and find 

them to be true and complete. 

Licensed Supervisor: " ••-: • ' -_• •; ' "^ . - •• - -::••::..::.-:-: . .'•:. .:.:•:;::; •.••-.'•^ :. > ;. ; .-, •; 

(Please Print) 

Licensed Supervisor: • Date: 

(Signature) 

I have personally reviewed this decommissioning checklist and site assessment report and the attachments and find 

them to be true and complete. 

Executive Officer: WiMmi 

Licensed Service Provider 

Executive Officer: 

Licensed Service Provider 

(Please Print) 

Date: 

(Signature) 

August 2007 Page 6 of 7 DEQ-08-LQ-073 
0 . REPORT FILING: 

This report signed by the permittee or tank owner, licensed supervisor and executive officer ofthe Service Provider, 

complete with all applicable attachments, must be filed with the DEQ regional office within 30 days after the excavation 

is backfilled or change-in-service is complete. Do not wait until any site related cleanup project is completed. Contact 

^ e DEQ regional office prior to filing this report where special circumstances exist at the site (such as water in pit, 

remaining pockets of contamination, etc.). 

P. HELP WITH THIS REPORT: 

If you have any questions about this decommissioning checklist and site assessment report, please phone your DEQ 

Regional Office. You can also phone the UST Program's toll-free number, 1-800-742-7878. This is a message answering 

machine for calls made within Oregon. Underground Storage Tank Program staff will retum your calls within 24 hours. 

You can also send an e-mail to tanks. info(i5).deq.state.or.us. Our regional staff are also available to answer questions 

regarding tank decommissioning or change-in-service requirements (see below for telephone numbers). 

Q. COPIES OF THE GENERAL PERMIT TO DECOMMISSION OR COMPLETE A CHANGE-IN-SERVICE: 

Obtain copies ofthe general permit to decommission or complete a change-in-service conditions and requirements, UST 

Program rules and laws and UST Cleanup rules and laws at: 

1. Any of the DEQ offices listed below, 

2. By calling the UST HELPLEME at 1-800-742-7878, 

3. Send an e-mail to tanks.info(S).deq.state.or.us or 

4. Downloading from the UST home page at: 

http://wvyw.deq.state.or.us/lq/tanks/ust/index.htni 

NORTHWEST REGION: 

Clackamas, Clatsop, 

Columbia, Multnomah, 

Tillamook & Washington 

Counties 

WESTERN REGION: Benton, 

Coos, Curry, Douglas, Jackson, 

Josephine, Polk, Lane, Lincoln, 

Linn, IVIarion & Yamhill Counties 

EASTERN 

REGION: 

Baker, Crook, 

Deschutes, 

Gilliam, Grant, 

Harney, Hood 

River, Jefferson, 

Klamath, Lake, 

Malheur, 

Mon'ow, 

Sherman, 

Umatilla, Union, 

Wasco, Wheeler 

& Wallowa 

Counties 

EASTERN REGION / THE DALLES 

400 E. Scenic Drive, Building 2 - 307 

The Dalles, OR 97058 

Phone: 541-298-7255 

Fax: 541-298-7330 

w 

NORTHWEST REGION 

2020 SW 4th Avenue, Suite 40() 

Portland, OR 97201-5884 

hone: 503-229-5263 

Fax: 503-229-6945 

WESTERN REGION / COOS BAY 

381 N SECOND STREET 

COOS BAY 97420 

Phone: 541-269-2721 

Fax: 541-269-7984 

WESTERN REGION / EUGENE 

1102 Lincobi Street, Suite 210 

Eugene, OR 97401 

Phone: 541-686-7838 

Fax:541-686-7551 

WESTERN REGION / SALEM 

750 Front Street NE, Suite 120 

Salem, OR 97301-1039 

Phone: 503-378-8240 

Fax: 503-373-7944 

August 2007 Page 7 of 7 DEQ-08-LQ-073